Download Management of a crown-root fracture in central incisors with 180

CASE REPORT
Safoora Sahebi1 DDS, MS, Vahid Dolatkhah2 DDS, Nooshin Sadat Shojaee2* DDS
Management of a crown-root fracture in central
incisors with 180° rotation: A case report
1. Assistant Professor of Endodontics, Dental School, Shiraz University of Medical Science, Shiraz, Iran.
2. Postgraduate Student of Endodontics, Dental School, Shiraz University of Medical Science, Shiraz, Iran. *Correspondence author E-mail:
[email protected]
ABSTRACT: The crown-root fracture is a common tooth injury which compromises the biological
width and need proper endodontic and prosthodontic treatment to achieve acceptable clinical
outcome. This case report describes clinical management of crown-root fracture in maxillary
central incisors which was successfully treated by forceps eruption with 180˚ rotation to restore
the biological width. The patient was followed-up for 18 months. Clinical and radiographic
evaluation showed acceptable results, the replanted teeth have normal function and no obvious
inflammatory root resorption was seen on radiographic examination.
KEYWORDS: Biologic width, Forceps eruption, Tooth fractures, Tooth injuries.
Received March 2011; accepted July 2011
INTRODUCTION
Maxillary central incisors are the most prone
teeth to traumas and injuries (1,2). The crownroot fracture is a common injury usually occur
after sever horizontal trauma. This type of tooth
injury is defined as a fracture involving enamel,
dentin, and root cementum and sometimes it
extends longitudinally to the subgingival area
(3) and compromise the biologic width (4). The
biological width is the distance from gingival
margin to crestal bone, involving biological
gingival sulcus; junctional epithelium and
conjunctive attachment (4). To perform a
coronal restoration, it is necessary to reestablish the biological width so that the margin
of restoration can be placed appropriately
without invading periodontal structures.
For establishing the invaded biological width
there are some therapeutic procedures such as
surgical extrusion with osteotomy and apical
placement of flap, and orthodontic extrusion
(5). Surgical extrusion cannot often provide
good esthetic results and relapse of the root is a
common finding as a result of stretched
marginal periodontal attachment in orthodontic
extrusion (6-8).
Forceps eruption or intentional replantation is
another therapeutic procedure to achieve
biologic width which was first introduced by
Tegsjö et al. (9) and then was developed by
Buhler (10) and Kahnberg et al. (11). Intentional
replantation with tooth rotation consists of
surgically tooth extraction and its placement in a
more coronally position; thus, this allows a
better restorative re-establishment, and recovers
biological width (4). According to Bender and
Rossman, the procedure is contraindicated in
teeth with periodontal disease and pronounced
mobility or gingival inflammation (12). The
success of this procedure is directly related to
accurate case selection based on clinical and
radiographic evaluation (3).
This case reports a crown-root fracture in
maxillary central incisors which was successfully
treated by forceps eruption with 180º rotation.
CASE REPORT
A 12-year old male was referred to Shiraz
Dental University, Department of Endodontics,
because of crown-root fracture of both maxillary
central incisors as a result of a bicycle accident 3
days before. The patient had no medical history;
periodontal status was normal based on clinical
inspection and periodontal probing. The roots had
no mobility and no sign of gingival inflammation
IEJ Iranian Endodontic Journal 2011;6(4):183-187
Forceps eruption 481
Figure 1. A: Maxillary central incisors with invasion of biological width. B: Fractured fragments of both teeth. C: Clinical
view (palatal) after coronal fragment was removed.
sufficient space for placement of composite
resin which was applied as a part of splint. This
2mm plug of composite resin would also
provide acceptable coronal seal until the
definitive restoration had been placed.
Figure 2. A: Radiographic image before treatment B:
Radiographic image after root canal therapy
or periodontal attachment loss was detected.
Clinical and radiographic
examinations
confirmed crown-root fracture (Figure 1A). The
vitality tests on adjacent teeth revealed that teeth
were all within normal limits. After local
anesthesia the fracture fragments were carefully
removed and the dental remnants were
disarticulated (Figure 1B). Delicate inspection
revealed that the teeth margins were placed
subgingivally and were extended apically to the
alveolar crest on the lingual side. As we
expected, the pulp injury had been occurred in
both teeth (Figure 1C). Intra-canal posts were
needed to accomplish good restorations. The
root end were mature and developed so that an
effective apical seal was expected (Figure 2).
Root canal therapy was performed on both
teeth. Under isolated condition using cotton rolls
the root canals were prepared. The canal
enlargement was conducted using Gates Glidden
drills no. 2, 3 (Dentsply, Maillefer, Ballaigues,
Switzerland) and ProTaper rotary instruments
(Dentsply, Maillefer, Ballaigues, Switzerland)
according to the manufacturer with 2.5% NaOCl
irrigation. After chemical and mechanical root
canal preparation, the canals were dried with
paper points, and then obturated with guttapercha and AH Plus (Dentsply DeTrey GmbH,
Konstanz, Germany) by lateral compaction
technique. Coronal 2mm of gutta-percha was
removed with a heated plugger to provide
IEJ Iranian Endodontic Journal 2011;6(4):183-187
The rotational forceps eruption was used in this
case due to extent of fracture and with the
purpose of recovering biological width with no
damage of clinical crown/root ratio, and to
have a better restorative re-establishment. The
parents were informed about the risks and
benefits of procedure and they assigned the
informed consent authorizing the procedure.
Teeth luxation was carefully performed with
rotational
motions
avoiding
excessive
compression of the periodontal ligament towards
the alveolar bone. Rotations with 180º provided
adequate recovering of the biological width. The
roots were inspected for any signs of crack or
fracture along their surface. The roots were fixed
with orthodontic wire no.5 splinted and light
cured resin was applied from the left lateral
incisor to the right lateral incisor. (Figure 3)
occlusal adjustment was then performed.
The patient was advised to eat a soft diet and
avoid biting with the injured teeth. Antibiotic
(amoxicillin 500mg) and 0.2% chlorhexidine
rinse were prescribed to prevent infection.
Seventeen days after replantation, slight
mobility was detected and the splint was
removed. The probing depths were normal and
re-attachment had been occurred in both of the
teeth. After 1 month follow-up, acceptable
clinical sign and symptoms was observed, then
the teeth were restored using a post and core
crown (Figure 4).
The patient was followed-up after 18 months.
Clinical and radiographic evaluation showed
Sahebi et al. 481
Figure 3. A. Clinical aspect of the 180˚ rotation and semi rigid splinting. B. Radiography after splinting. C, D. Clinical
photography and radiography after post and core restoration
Figure 4. 18 months follow-up, clinical photography
and radiography shows acceptable esthetic result and
periodontal/periapical status.
acceptable results in mobility test, probing
depth, clinical attachment level. There were not
any evidence of root resorption and alveolar
bone integrity was maintained.
DISCUSSION
The intentional replantation was first performed
by Tegsjö et al. and is indicated in cases of
crown-root fractures, cervical caries, root
resorption or perforations (4). Kim et al.
described surgical extrusion procedure in which
after gentle luxation of the tooth, the position of
the tooth was adjusted according to the new
biologic width (13). They showed that
periodontium can be recovered functionally and
esthetically.
There are limited data on the survival rate of
intentionally replanted teeth. It is obvious that
fracture of the teeth or alveolar bone which
lead to missing of teeth is the most concern.
Root resorption, inflammatory response or
ankylosis can be seen in dental replantation
procedures. Success rate of intentional
replantation was reported between 72.0% and
80.6% (12,14). A traumatic handling and
stabilization of the root were found to be the
critical points for achieving good results (15).
Kahnberg (15) demonstrated excellent 5 years
prognosis for the survival of the teeth which
had been treated with this method.
Furthermore, complete healing of periodontal
ligament was observed in 75% of cases. Bender
and Rossman (12) reported success rate of
80.6% for this procedure in cases of previously
failed conventional endodontic treatment teeth.
They recommended this method for cases which
are difficult in accessibility and when there are
anatomical limitations. They stated contraindication of this method in cases with high
mobility and gingival inflammation. Khayat and
Fatehi demonstrated successful outcomes for
this procedure (16). In this study none of the
cases showed ankylosis, abnormal mobility, and
sensitivity to percussion or palpation. PDL
healing was found in 95% of cases after 12
months. But authors also suggest further
evaluation of the cases.
Minimal trauma to periodontal ligament, which
reduces ankylosis and root resorption of the
tooth, is the most critical factor for success.
When trauma to the PDL fibers is minimal, the
healing process occurs by cemental healing
which leads to normal structure of the
periodontium. In cases of severe trauma the
chance of root resorption or ankylosis increases
(17). Preserving sever traumatized tooth, like
intrusion or avulsion with prolonged extra-oral
time, should be considered with caution.
Ankylosis will replace the whole root with
bone, arrest the growth of the alveolar process,
then tooth will be infra-occlusion. The worst
outcome is sever bone defect which is very
difficult to recover (18,19). Therefore, if the
possibility of ankylosis is high, preserving the
tooth is not logical.
The time for the re-attachment of the PDL fibers
is about two weeks (20). When the procedure is
non-traumatized inflammation is minimum;
therefore, PDL cells can differentiate properly
and normal re-attachment can be occurred. An
old animal study in which intentional replantation
on dogs performed showed that periodontal
ligament can be re-establish successfully and
teeth can survive permanently (21).
In making decisions for treatment of these
IEJ Iranian Endodontic Journal 2011;6(4):183-187
Forceps eruption 481
teeth, patient age, root developmental stage,
patient preference and final outcome of each
treatment option should be considered.
There were some possible options for the
treatment of this case: orthodontic force
eruption, surgical crown lengthening with
osseous surgery, decoronation of the teeth and
temporary partial denture, and forceps eruption
(intentional replantation). Among these options,
forceps eruption was selected. Intra-alveolar
transplantation or forceps eruption is a kind of
intentional replantation which is done in cases of
complicated crown root fracture (9).
Considering the esthetic importance in anterior
part of the jaw, treatment of the teeth with crown
root fractures or deep cervical root caries, can be
completed with this method, long duration
follow-ups indicated the good long-term
prognosis for these teeth (22). Replantation of
fractured teeth with compromised margins
below the gingival border or bone can improve
achieving
better
periodontal
healing.
Development of narrow periodontal pockets
along the fracture line will be avoided (23). In
anterior teeth especially in upper jaw when a
deep lingual crown root fracture occurs, tooth
can be rotated towards facial side to achieve a
more accessible coronal position of the fracture
line. This approach is beneficial for reestablishing the biologic width and placement of
permanent restoration (3). In this case, incisors
were rotated 180º due to the deep fracture line
and satisfactory coronal restorations were
placed. Another reason for this rotation was the
retention of the root in the socket. One of the
drawbacks of replantation technique is that the
periodontal ligament may fail to attach on the
root surface (24), but in this case 18 months
follow-up
revealed
healthy
periodontal
attachment without any pocket in both teeth. In
this case, forceps eruption was the only possible
choice between the 4 mentioned options.
Orthodontic forced eruption was not a good
option because it could lead into the undesirable
coronal movement of marginal gingiva and
alveolar bone. On the other hand relapse of the
extruded tooth is a major problem which can
compromise the results (16). Additionally, this
procedure is expensive and time consuming.
Surgical crown lengthening with apically
positioned flap involves surgical removal of the
IEJ Iranian Endodontic Journal 2011;6(4):183-187
marginal gingiva; it can lead to undesirable
esthetic results. Performing this procedure,
especially in the anterior of the maxilla, should
be done with caution. This procedure is
contraindicated in patients with high exposure of
gingival margin. Surgical crown lengthening
also requires osteotomy in this region and it has
been said that it could cause resorption of the
labial cortical plate and could later compromise
the bone configuration for placing dental
implants (18). Surgical crown lengthening
should be considered with caution. If the
prognosis of this treatment is questionable, it
should be ruled out.
It should be noted that placement of implant
during childhood is contraindicated (25). It has
been suggested that the ideal age for implant
placement is at the end of alveolar growth (18).
Since implants act like an ankylosed tooth,
therefore placing an implant before this period
will lead to infra-occlusion of the implant. The
age of 18 is an ideal time for placement of
implant, so considering the age of this patient (11
years old) implant cannot be not a good option.
After removing the coronal fractured segments
the teeth was evaluated for the amount of
crown/root ratio, which is important for
placement of the cast post and core restoration.
If the crown/root ratio was not acceptable, the
roots of the fractured teeth should be preserved
till 18. Since the extraction of the teeth in this
region will lead to 40% to 60% bone loss in the
first year, especially in the facial part of the
alveolar ridge, extraction of these roots is
contraindicated (26). The preservation of the
roots until the completion of alveolar growth
has been suggested. The coronal part of the
roots should be blunted with a chisel instrument
because the sharp edges of the tooth will
compromise the healing process in involved
area. Then the roots will be covered with a
mucoperiosteal flap. The remaining root will
preserve the labiolingual portion of the alveolar
process. When the growth has been completed,
the alveolar structure will be optimal for
implant placement (27,28).
CONCLUSION
Forceps eruption is one of the alternative
procedures in complicated crown root fractures in
order to maintain the damaged structures at health
Sahebi et al.481
condition aesthetically and functionally. For
successful treatment, atraumatic extraction
techniques, limited extra-oral time to control
damage of the periodontal ligament and
appropriate antibiotic therapy for microbiological
control should be correctly indicated and
performed by dental practitioner in well selected
cases. Clinical and radiographic follow-up should
be carried out for 5 years.
Conflict of interest: none declared.
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